| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Floors, walls, ceilings and other surfaces are not in good repair. The door frame in Individual #2's bathroom was missing the molding on the side of the frame where the door latch is located.
The sliding doors located on the laundry area are broken and falling off. | Floors, walls, ceilings and other surfaces shall be in good repair. | Provider has implemented a Quality Assurance tool to ensure property is in good repair and shape. This tool will be completed by the Program Manager monthly and forwarded to Director for review.
(molding and sliding door repaired -CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.67(b) | Floors, walls, ceilings, and other surfaces are not free from hazards. The door frame around Individual #1's bedroom and the bathroom located off of Individual #2's bathroom have peeling paint. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider has implemented a Quality Assurance tool to ensure property is in good repair and shape. This tool will be completed by the Program Manager monthly and forwarded to Director for review.
(paint repaired -CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.141(a) | Individual #2 did not have a physical examination within 12 months prior to admission. Individual #2 was admitted to the program on 2/8/22 and did not have a physical examination completed until 4/21/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions. |
04/01/2023
| Implemented |
| 6400.141(c)(4) | Individual #2 has not had an annual hearing examination completed. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions. |
04/01/2023
| Implemented |
| 6400.142(a) | Individual #2 has not had a dental examination completed since admission on 2/8/22. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions.
(dental examination scheduled 5/8/23 -CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.142(f) | Individual #2 does not have an annual dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Provider has created an admissions tracking sheet that reflects all required documentation prior to admissions.
(dental appointment scheduled -CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.144 | Health services including scheduling of follow up medical appointments has not been planned for. Individual #2's Primary Care Physician recommended follow up for hearing, with Gastroenterology for a colonoscopy and for follow up on 4/21/22. There have been no appointments scheduled to complete the follow up. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Program Specialist and Program Manager will track required medical appointments and ensure appointments are made according to need and requirements.
(colonoscopy completed 4/24/23 - CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.46(b) | Staff #6 received fire safety training on 5/5/22, however there is no documentation to support that the training was completed by a fire safety expert and included the training areas specified in subsection (a). | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Provider has contracted with Allentown Fire Department to facilitate the annual fire training. Captain Christopher will be facilitating the training on May 10 & May 17. |
06/01/2023
| Implemented |
| 6400.50(a) | Records of training for annual training in Recognizing and Reporting Incidents dated 12/9/22 for Staff #6 did not include the length of training.
Records of training for fire safety training completed on 5/5/22 for Staff #6 did not include the training source and content of training.
Staff #6 received a Certificate of Completion from the American Red Cross for Adult First Aid and CPR on 4/29/22. The certificate did not include the length of training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Providers trainer has updated the training sign in sheet to reflect more detail, including the length of time and training content. |
05/01/2023
| Implemented |
| 6400.52(c)(2) | Staff #6 did not complete annual training in the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.§§ 10225.101-10225-5102), the Child Protective Service Law (23 Pa. C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Provider has created a yearly calendar to reflect all necessary yearly trainings, as well as "new hire orientation" trainings.
(staff trained 4/17/23 -CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.195(a) | Individual #2 does not have a bedroom door. Individual #2's Individual Support Plan (ISP) states "CURTAIN AS DOOR TO BEDROOM: A FABRIC CURTAIN TO BE USED IN PLACE OF A WOODEN OR METAL DOOR TO PROTECT THEM IN THE EVENT OF A BEHAVIORAL EPISODE." Individual #2's right to lock the bedroom door is being denied due to behavioral concerns. There is no component addressing behavior supprt being reviewed and approved by a human rights team for the use of restrictive procedures. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | A restrictive procedure plan was created to reflect the need for the door being of the hinges. This plan has been reviewed and approved by the Human Rights Committee. |
04/14/2023
| Implemented |